X Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.
8.1. Is cost-sharing imposed on any of the children covered under the plan?
8.1.1. ~ YES
8.1.2. ~ NO, skip to question 8.5.
8.2. Describe the amount of cost-sharing and any sliding scale based on income: Section 2103(e)(1)(A))
8.2.1. Premiums:_______________________________________
8.2.2. Deductibles:______________________________________
8.2.3. Coinsurance:______________________________________
8.2.4. Other:___________________________________________
8.3. Describe how the public will be notified of this cost-sharing and any differences based on income:
8.4. The state assures that it has made the following findings with respect to the cost sharing and payment aspects of its plan: (Section 2103(e))
8.4.1. ~ Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B))
8.4.2. ~ No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2))
8.4.3. ~ No child in a family with income less than 150% of the Federal Poverty Level will incur cost-sharing that is not permitted under 1916(b)(1).
8.4.4. ~ No Federal funds will be used toward state matching requirements. (Section 2105(c)(4))
8.4.5. ~ No premiums or cost-sharing will be used toward state matching requirements. (Section 2105(c)(5)
8.4.6. ~ No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A))
8.4.7. ~ Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1))
8.4.8. ~ No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B))
8.4.9. ~ No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A))
8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s annual income for the year involved: (Section 2103(e)(3)(B))
8.6. The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan:
8.6.1. ~ The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR
8.6.2. ~ The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.3.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2109(a)(1),(2)). Please describe:
